Graham Davey's Blog

Sunday, 24 March 2013

Graham Davey's Blog has moved to http://www.papersfromsidcup.com/graham-daveys-blog.html.You can find all previous blogs posted here archived at the new address.All new posts will also appear at http://www.papersfromsidcup.com/graham-daveys-blog.html

Wednesday, 27 February 2013

That's
rather an extreme blog post title, but was inspired by the APA's (American
Psychiatric Association) recent
comment that "Many of the revisions in DSM-5 will help
psychiatry better resemble the rest of medicine". This alone would be
enough to send shivers down the spine of most psychology-minded mental health
practitioners, but it led me to thinking about where that might leave
psychology as a rather different knowledge-based approach to understanding and
treating mental health problems.

Specifically,
if the APA want to impose a medical model on mental health then what will our
doctors and physicians be learning about how to deal with their patients with
mental health problems? The incremental implications are immense. It is not
just that mental health is being aligned with medicine on such an explicit
basis in this way, this issue is compounded by the fact that medical training
still plays lip service to training doctors in psychological knowledge and, in
particular, to a psychological approach to mental health. So has medicine taken
the decision to align mental health diagnosis and treatment to fit the
constraints of current medical training (rather than vice versa)?

I
returned to a President's
column I wrote in 2002 about the state of psychology teaching in the UK
medical curriculum. The same points I made then seem to apply now. The
medical curriculum is not constructed in a way that provides an explicit slot
for psychology or psychological knowledge. Even though a recent manifesto for
the UK medical curriculum (Tomorrow’s
Doctors, 2009) makes it clear that medical students should be able to
“apply psychological principles, method and knowledge to medical practice”
(p15), there is probably no practical pressure for this to happen. Given that
the ‘Tomorrow’s Doctors’ document does advocate more behavioural and social
science teaching in the medical curriculum, I suspect that what happens in
practice is that a constrained slot for ‘non-core medical teaching’ gets split
up between psychology, social science and disciplines such as health economics.
If a medical programme decides to take more sociology (because there are
sociologists available on campus to teach it) – then there will be less
psychology.

The
second point I made then was related to the expectations of medical students.
This was illustrated by a QAA report for a well-respected medical school. This made
the point that:

“...there was a student perception that, in
Phase I, the theoretical content relating to the social and behavioural
sciences was too large. Particular concern was expressed about aspects of the
Health Psychology Module....a number of students suggested that the emphasis
placed upon theoretical aspects of these sciences in Phase I was onerous”

Well – death to
psychology! My own experience of teaching medical students is that they often have
a very skewed perception of science, and in particular, biological science.
Interestingly, the ‘Tomorrow’s Doctors’ document advises that medical students
should be able to ‘apply scientific method and approaches to medical research’
(p18). But in my experience medical students find it very difficult to
conceptualize scientific method unless it is subject matter relevant – i.e.
biology relevant. I have spent many hours trying to explain to medical students
that scientific method can be applied to psychological phenomena that are not
biology based – as long as certain principles of measurement and replicability
can be maintained.

But there has
been a more recent attempt to define a core curriculum for psychology in
undergraduate medical education. This was the report from the Behavioural
& Social Sciences Teaching in Medicine (BeSST) Psychology Steering Group
(2010) (which I believe to be an HEA Psychology Network group). I am sure
this report was conducted with the best of intentions, but I must admit I think
it’s core curriculum recommendations are bizarre, and entirely miss the point
of what psychology has to offer medicine! It is like someone has gone through a
first year Introduction to Psychology textbook and picked out interesting
things that might catch the eye of a medical student – piecemeal! For example, the
report claims that learning theory is important because it might be relevant to
“the acquisition and maintenance of a needle phobia in patients who need to
administer insulin” (p30). That is both pandering to the medical curriculum and
massively underselling psychology as a paradigmatic way of understanding and
changing behaviour!

Medical students need to understand that psychology is an entirely
different, and legitimate, method of knowledge acquisition and understanding in
biological science. Not all mental health problems are reducible to biological
diagnoses, biological explanations or medical interventions, and attempts by
the APA to shift our thinking in that direction are either delusional or self-promoting.
What is most disappointing from the point of view of the development of mental
health services is the impact that entrenched medically-based views such as
those of the APA will have on the already introverted medical curriculum.
Doctors do need to learn about medicine, but they also need to learn that
mental health needs to be understood in many ways – very many of which are not traditionally
biological in their aetiology or their cure.

Thursday, 21 February 2013

Another short piece written as a Focus Point for the second edition of my Psychopathology textbook (due to be published late 2013).DSM regularly
undergoes an intensive revision process to take account of new research on
mental health problems and to refine the diagnostic categories from earlier
versions of the system. One would assume that this would be a deliberate and
objective process that could only further our understanding of psychopathology,
and that is certainly the intention of the majority of those involved. However,
at least some people argue that the process of developing a classification
system such as DSM can never be entirely objective, free from bias, or free
from corporate or political interests. Allen Frances and Thomas Widiger were
two individuals who were prominent in the development of the fourth edition of
the DSM, and they have written a fascinating account of the lessons they
believe should be learned from previous attempts to revised and develop mental
health classification systems (Frances & Widiger, 2012).
They make the following points:

1. Just as the number of mental health
clinicians grows, so too will the number of life conditions that work their way
into becoming disorders. This is because the proliferation of diagnostic
categories tends to follow practice rather than guide it.

2. Because we know very little about the
true causes of mental health problems, it is easier and simpler to proliferate
multiple categories of disorder based on relatively small differences in
descriptions of symptoms.

3. Most experts involved in developing DSM
are primarily worried about false negatives (i.e. the missed diagnosis or
patient who doesn’t fit neatly into the existing categorizations), and this
leads to either more inclusive diagnostic criteria or even more diagnostic
categories. Unfortunately, experts are relatively indifferent to false
positives – patients who receive unnecessary diagnosis, treatment, and stigma –
and so are less likely to be concerned about over-diagnosis.

4. Political and economic factors have also
shaped the ‘medical model’ view of psychopathology on which DSM is based, and
also contributed to the establishment and proliferation of diagnostic
categories. For example, the pharmaceutical industry benefits significantly
from the sale of medications for mental health problems, and its profits will
be dependent on both (1) conceptions of mental health based on a medical model
that implies a medical solution, and (2) a diagnostic system that will err
towards over-diagnosis rather than under-diagnosis (see Pilecki, Clegg & McKay,
2011).

Wednesday, 13 February 2013

As promised, it's my intention to post some new pieces written for the second edition of my Psychopathology textbook (due to be published late 2013). This post begins that process with a new section written to introduce and evaluate DSM-5 from the Chapter on Classification & Assessment in Clinical Psychology.

"Published in
2013, DSM-5 arguably represents the most comprehensive revision of the DSM so
far, and it has involved many years of deliberation and field trials to
determine what changes to mental health classification and diagnosis are essential
and empirically justifiable (Main chapter headings for DSM-5 are provided in
Table 1).

The main changes
between DSM-5 and its predecessor (DSM-IV-TR) are listed in Table 2.

First,
previous versions of DSM placed mental health problems on a number of different
axes representing clinical disorders (Axis I), developmental and personality
disorders (Axis II), or general medical conditions (Axes III). This multiaxial
system has been scrapped – largely because there was not enough evidence to
justify the differences between them. Instead, in DSM-5 clinicians will be
encouraged to rate severity of symptoms along continuums developed for each
disorder. Secondly, the importance of some disorder categories has been
recognised either by allocating them to their own chapter or by recognising
them as new individual diagnostic categories. For example, Obsessive-Compulsive Disorder (OCD)
is recognized as a significant mental health problem by being allocated it’s
own chapter in DSM-5, and new diagnostic categories within this chapter include
Hoarding Disorder (see Chapter 6) and Excoriation Disorder (skin-picking
disorder). Similarly, DSM-5 has a new chapter on Trauma & Stress-Related
Disorders that now includes Post-Traumatic Stress Disorder
(PTSD). DSM-5 focuses more on the behavioural symptoms that accompany PTSD and
proposes four distinct diagnostic clusters instead of the previous three.
Thirdly, major changes have been made to the criteria for diagnosing Autism
Spectrum Disorder (ASD), Personality Disorders, Specific Learning Disorders,
and Substance Use Disorders. Autistic Spectrum Disorder has
become a diagnostic label that will incorporate many previous separate labels
(e.g. Asperger’s disorder, childhood disintegrative disorder, pervasive
developmental disorder) in an attempt to provide more consistent and accurate
diagnosis for children with autism (see Chapter 16). DSM-5 will retain the
categorical model for Personality Disorders outlined in
DSM-IV-TR, but rating scales are provided to assess how well an individual’s
symptoms fit within these different types (Chapter 12). The new Specific
Learning Disorder category is broadened to represent distinct disorders
which interfere with the acquisition and use of one or more of a number of
academic skills, including oral language, reading, written language or
mathematics (Chapter 15), and the new Substance Use Disorder category will
combine the previous DSM-IV-TR categories of substance abuse and substance
dependence into one overarching disorder. Some other important changes include
(1) the elevation of Binge Eating Disorder from an
appendix to a recognized diagnostic category, (2) Disruptive Mood Regulation
Disorder as a new category for diagnosing children who exhibit
persistent irritability and behavioural outbursts, and (3) the removal of the
“bereavement exclusion” from the diagnosis of Major Depression; this
means that depressive symptoms lasting less than two months following the death
of a loved one can be included amongst the criteria for diagnosing Major Depression,
and reflects the recognition that bereavement is a severe psychological
stressor that can precipitate major depression.

Criticisms of Changes in DSM-5: While these
most recent changes to the DSM have been extensively discussed and researched,
many of the revisions have been received critically, and it is worth discussing
some of these criticisms because they provide an insight into the difficulties
of developing a mental disorders classification system that is fair and
objective.

First, many of the
diagnostic changes will reduce the number of criteria necessary to establish a
diagnosis. This is the case with Attenuated Psychosis Syndrome, Major
Depression, and Generalized Anxiety Disorder, and this runs the risk of
increasing the number of people that are likely to be diagnosed with common
mental health problems such as anxiety and depression. It is a debatable point
whether increases in the number of diagnosed cases is a good or a bad thing,
but it is likely to have the effects of “medicalizing” many everyday emotional
experiences (such as ‘grief’ following a bereavement, or worry following a
stress life event), and creating “false-positive” epidemics (Frances, 2010).

Secondly, DSM-5
has introduced disorder categories that are designed to identify populations
that are at risk for future mental health problems, and these include Mild
Neurocognitive Disorder (which would diagnose cognitive decline in the
elderly) and Attenuated Psychosis Syndrome (seen as a potential precursor to
psychotic episodes). Once again, these initiatives run the risk of medicalizing
states that are not yet full-blown disorders, and could facilitate the
diagnosis of normal developmental processes as psychological disorders.

Thirdly, there
are concerns that changes in diagnostic criteria will result in lowered rates
of diagnosis for some particularly vulnerable populations. For example,
applying the DSM-5 criteria for Autism Spectrum Disorder to samples
of children with DSM-IV-TR diagnoses that would no longer be available in DSM-5
suggested that 9% of this latter group would lose their autism diagnosis with
the introduction of the new DSM-5 criteria (Huerta, Bishop, Duncan, Hus
& Lord, 2012). Similar concerns have been voiced about changes to Specific
Learning Disorder diagnostic criteria in DSM-5, and the possibility
that deletion of the term dyslexia as a diagnostic label will
disadvantage individual with specific phonologically-based, developmental
reading disabilities (http://www.disabilityrightsohio.org/news/dsm5-dyslexia-june-2012).

Finally, two
enduring criticisms of DSM generally that have continued to be fired
specifically at DSM-5 have been that (1) DSM-5 has continued the process of
attempting to align it’s diagnostic criteria with developments and knowledge
from neuroscience (Regier,
Narrow, Kuhl & Kupfer, 2011), when there is in fact very little new
evidence from neuroscience that helps define specific mental health problems,
and (2) most mental health problems (and psychological distress generally) are
now viewed as dimensional, so any criteria defining a diagnostic cut-off point
will be entirely arbitrary. DSM-5 has attempted to recognise the importance of
the dimensionality of symptoms by introducing dimensional severity rating
scales for individual disorders. But as we have seen from the discussion above,
each iteration change in DSM diagnostic criteria changes the number and range
of people who will receive a diagnosis, and this makes it increasingly hard to
accept diagnostic categories as valid constructs (e.g. Kendler, Kupfer, Narrow,
Phillips & Fawcett, 2009).

Despite its
conceptual difficulties and its many critics, DSM is still the most widely
adopted classification and diagnostic system for mental health problems. Such a
system is needed for a number of reasons, including determining the allocation
of resources and support for mental health problems, for circumstances that
require a legal definition of mental health problems, and to provide a common
language that allows the world to share and compare data on mental health
problems. Having said this, there are still many significant problems
associated with DSM, and diagnosing and labelling people with specific
psychological disorders raises other issues to do with stigma and
discrimination. Indeed, we should be clear that diagnostic systems are not a
necessary requirement for helping people with mental health problems to
recover, and many clinical psychologists prefer not to use diagnostic systems
such as DSM-5, but instead prefer to treat each client as someone with a unique
mental health problem that can best be described and treated using other means
such as case
formulation (see Section 2.3 for a fuller description and examples
of case formulation)."